Synopsis

A 2008 survey of chronically ill adults in Australia, Canada, France, Germany, the Netherlands, New Zealand, the United Kingdom, and the United States found major differences in health care access, safety, and efficiency, with U.S. patients at particularly high risk of forgoing care because of costs and experiencing errors or inefficient, poorly organized care.

The Issue

Across industrialized nations, patients with multiple chronic conditions account for a disproportionate share of national health spending. Such patients often see multiple clinicians in a variety of care settings, putting them at heightened risk for experiencing medical errors and having poorly coordinated care. Because of their extensive contact with the health care system, these patients offer unique perspective on many aspects of system performance.

Key Findings

More than half (54%) of U.S. patients did not get recommended care, fill prescriptions, or see a doctor when sick because of costs, versus 7 percent to 36 percent in the other countries.

About one-third of U.S. patients—the highest proportion in the survey—experienced medical errors, including delays in learning about abnormal lab test results.

Similarly, one-third of U.S. patients encountered poorly coordinated care, including medical records not available during an appointment or duplicated tests.

The U.S. stands out for patient costs, with 41 percent reporting they spent more than $1,000 on out-of-pocket costs in the past year. U.K. and Dutch patients were most protected against such costs.

Only one-quarter (26%) of U.S. and Canadian patients reported same-day access to doctors when sick, and one-fourth or more reported long waits. About half or more of Dutch (60%), New Zealand, (54%), and U.K. (48%) patients were able to get same-day appointments.

A majority of respondents across the eight countries saw room for improvement. Chronically ill adults in the U.S. were the most negative; one-third said the health care system needs a complete overhaul.

In the past two years, 59 percent of U.S. patients visited an emergency room (ER); only Canada had a higher rate (64%). In both countries, one of five patients said they went to the ER for a condition that could have been treated by a regular doctor if one had been available.

Study Implications

While the U.S. did comparatively well on some measures of hospital discharge instructions and patient-centered care, chronically ill Americans often cannot afford to follow recommended care. Gaps in coverage and cost-sharing are undermining access and adherence. The survey finding that in all eight countries, patients most often reported that errors happened outside the hospital highlights the need to focus on ambulatory care and medication safety. Initiatives under way across nations to improve performance through payment reform, information systems, and managing chronic conditions offer cross-national opportunities to learn.

The Bottom Line

Compared with their counterparts in seven other countries, chronically ill adults in the U.S. are far more likely to forgo care because of costs. They also experience the highest rates of medical errors, care coordination problems, and high out-of-pocket costs.

Mission

The mission of The Commonwealth Fund is to promote a high-performing health care system that achieves better access, improved quality, and greater efficiency, particularly for society's most vulnerable, including low-income people, the uninsured, minority Americans, young children, and elderly adults.